Media•on June 20th, 2017•Comments Off on LIFT the TriState Application

Please complete this application accurately and legibly. The information provided here will be used by Freestore Foodbank staff to better understand each potential trainee's situation and needs. All information will remain confidential.

All instruction and testing for this program is conducted in English. Are you able to read, write and communicate in English proficiently?YesNo

Are you able to regularly perform required warehouse duties as assigned for a 8 hour day? Including but not limited to: • Standing for long periods of time • Ability to bend and lift a minimum of 50lbs • Able to drive and operate powered equipment safely

YesNo

ADDITIONAL INFORMATION:

How did you hear about the LIFT the TriState program?Gateway CollegeCustomer Connection Center, Freestore FoodbankFacebookFriend/FamilyBelflexOther

Other:

Why are you interested in this program? (2-3 sentences):

EMERGENCY CONTACT INFORMATION

Name:

Relationship to you:

Phone Number:

EMPLOYMENT HISTORY: (Please provide complete information on your last three jobs, starting with the most recent. Note: Warehouse experience is not a requirement for admission into the LIFT the TriState program).

Employer (Company Name):

Name of Supervisor:

Supervisor's Phone#:

Job Title:

Duties/Responsibilities:

Start Date:

End Date:

Reason for Leaving:

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Employer (Company Name):

Name of Supervisor:

Supervisor's Phone#:

Job Title:

Duties/Responsibilities:

Start Date:

End Date:

Reason for Leaving:

SOCIAL SERVICES INFORMATION:

Do you have a Case Worker/ Case Manger?YesNo

Name:

Agency:

Phone#:

Email:

Do you currently have a source of income?YesNo

Please select the source(s) of income you currently receive:EmploymentFamily SupportUnemploymentSocial SecuritySocial Security DisabilityOther

Other (Please explain):

Are you currently receiving any of the following benefits or services?Food StampsMedicaid/AHCCCSCash AssistanceSSIUnemployment BenefitsOtherNone

Other (Please explain):

The staff at Freestore Foodbank wants to help all those who are enrolled in the program become as healthy, independent, and self-sufficient as they can be. Please select any areas that you need assistance with:

I certify that my answers are true and complete to the best of my knowledge. If this application leads to enrollment in the program, I understand that false or misleading information in my application or during my interview may result in my release from the program. If this application leads to enrollment in the program, I understand that I may be asked to take and pass a physical exam, drug and alcohol screening, and/or have a doctor's release to participate.